My name is Dr. Mohamed
Raslan from Egypt currently working in Rod Elfarag National Eye Institute.
I sat my FRCS (Glasgow) in New Delhi in September 2006 and thanks ALLAH
I passed. My special thanks go to Dr.Ayman Elghoniemy & Dr.Hussien
Swelem for their selfless help and support. To succeed, I recommend constant
practice of common clinical techniques, discussions of common questions
with colleagues so that you are fluent with the oral examination. This
site contains past candidates' experience which all potential candidates
should visit.

1st Day : Clinical case interpretation

1. 75 year old woman has been attending
the clinic for some time with an indolent left corneal ulcer. There is
a history of joint pains and weight loss, and she has dry eyes. She presents
acutely with worsening pain in her left eye and blurring of vision .on
exam u notice the ulcer has perforated with flat AC. Describe acute and long term management
and what investigations are appropriate.

Answer: DD should include causes of resistant
ulcer with dry eye and collagen diseases, infective keratitis, and work
up: for perforated ulcer, including team work with rheumatologist, and
long term ttt of dry eye with attention to other eye.

2. A 3 years old boy has been seen at
the clinic for 2 years with bil. Watering & has had 2 probing procedure
performed. On both occasions the probe was passed easily. The Rt. Eye has
settled but on the left side he is having recurrent dacryocystitis every
few months requiring systemic antibiotics. His parents are angry and are
demanding something is done or a second opinion is given. Explain how you
would manage this situation & write a letter to the GP detailing your
action.

Answer : The action is straightforward.
I mentioned the surgical options includ either intubation or DCR after
work up for epiphora, but the important point in the question is how to
deal with the parental concern.

3. A 50 year old male artist in known
to have small bilateral inferior retinoschisis. He presents to his optician
having become aware of some distortion in his right eye with a change in
color perception. The optician thinks the retinoschisis has enlarged on
the right side and is now encroaching onto the macular area. The patient
is referred for your opinion. What is your differential diagnosis, and
how to investigate and manage him?

Answer: The main part of the answers should
be the differences between retinoschisis and retinal detachment: relative
versus absolute visual defect, presence of holes and pigmentations, effects
of focal laser on the retina between the two conditions. Finally the treatment
options. Other differential diagnosis include optic neuropathy, macular
disease, and other causes of visual distortion.

2nd Day: Viva

General medicine &Neurology(An English Ophthalmologist and an
Indian Physician)

The English Examiner:

A laptop picture of bilateral proptosis with
lid retraction. The patient also had heat intolerance. I diagnosed
thyroid eye diseases and was asked about the other ocular features of thyrotoxicosis:
optic neuropathy, corneal exposure, and restrictive moypathy and lid signs.
I was also asked about the systemic signs and symptoms: tremors, weight
loss, diarrhea, muscle weakness, nervousness, and atrial fibrillation.

Asked to look at the visual field of a 52
old-lady. The field indices showed it was reliable. It was a 24-2 SITA,
there was a right absolute upper altitudinal scotoma so I gave a differential
diagnosis which include: ischemic optic neuropathy lower branch a.
occlusion or branch retinal occlusion. Asked about the typical features
of giant cell arteritis and I mentioned if if she is 70 years old with
difficult mastication I would consider giant cell arteritis with arteritic
anterior ischaemic optic neuropathy. Questions on management,
the reliability of ESR, C-reactive protein. How to give steroid and the
preliminary investigations before the steroid was given. Also about pulse
steroid therapy. Temporal artery biopsy, how long after steroid institution
will the histology be negative and what to do if biopsy is normal? Would
I do the other side if the result is normal? How to monitor the patient's
progress?.

What is benign intracranial pressure? I mentioned
bilateral palloedema with normal brain imaging and normal CSF analysis.
I also said high opening pressure by lumber puncture and was asked what
is the normal values? I mentioned less than 20cm H2O
and 25 in obese patients. Asked how to manage the patient? I said this
should be managed jointly between the ophthalmologist and the neurologist.
Options include: Conservative: weight loss ,stop drug if patient is on
any that are associated with BIP, follow up for headache severity and regular
visual field testing. Medical management include acetazolamide and if this
failed surgical treatment such as shunt for persistant raised pressure
with disabling headache and optic nerve fenestration if there is progressive
visual loss.

The Indian examiner

What are the ocular complications of rhematoid
arthritis (RA)? Dry eye, scleritis, episcleritis, preph.corneal ulcer,
corneal melting. What is the treatment for RA? , NSAID, hydroxychloroquene,
steroids. How about antimetabolites? Methotrexate and azathioprine. Asked
which is better chloroquine or hydroxychloroquine? I mentioned hydroxychloroquine
is better as it has less retinal toxicity. What is the toxic dose
of hydroxychloroquine? 6.5 mg/kg/day of hydroxychloroquine and 3mg/kg/day
for chloroquine for 5 years. What are the other arthropthies affecting
the eyes? Ankylosing spondylitis, SLE, juvenile rheumatoid arthritis, sarcidosis.
How to differentiate between RA and SLE? Clinically SLE does not usually
cause joint deformities, there are malar flushes, more severe systemic
complication such as renal failure, lung desease and cardiomoypathy.
Laboratory test is positive for anti-DNA antibodies in SLE.

During fluorescence angiography, a patient
experienced tachycardia and difficulty with breathing. How would you manage
the situation? I will consider possible anaphylatic shock. The action to
take include stopping the injection, assessing ABC, shouting for
help. Give 100% O2 mask,
give 0.5 mg adrenaline im which can be repeated after 5 minutes.
10 mg iv chlorpheneramine, 200 mg hydrocortisone, saline intravenous. How
about if the patient fails to improve? Call for help again, give nebulized
bronchodilators such as salbutamol. If still not improvement? Refer to
icu for intubation and mechanical ventilation.

What are the side effects of steroids? How
do you diagnose osteoporosis? Clinically bone and joint pain, bone scan
will show decreased bone density and T score of DXA is below -2.5.

Ophthalmic Surgery & Pathology(2 Indian Examiners)

First examiner

What is granuloma? Chronic inflammatory reaction
with predominance of macrophages which may aggregate to form giant cells
and lymphocytes what are the Types of giant cells? How can u differentiate
bet.them? Examples of granulomas affecting the eye and there giant cell
types?

What is pannus? Fibrovascular ingrowth Which
layer of the cornea does it affect? Sub epithelial Examples of diseases
that cause pannus? Trachoma, contact lens SLK, rosacea.

A picture of Lester Jones tube. What is it
made of? Silicone and no glass. Indications? Obstruction of canaliculi.
How can you control bleeding during DCR? I classified them as pre, intra,
and post-operative measures then mentioned them in details.

A scenario of a patient hitten by a squash
or a tennis ball what each ball may cause? If presents with diplopia how
would u manage? 1st I will exclude globe rupture, retrbulbar hge, globe
is free I will suspect fracture of the floor. Investigations? Assess
ocular motility, sensation along infraorbital nerve., and CT how would
u order the CT? Coronal section with 2mm cuts.

Second Examiner

What type of cataract surgery do you do? ECCE.
What type of suture do you use? Nylon 10/0. What are the other types of
sutures used in ophthalmology? Uses of vicryl? How can you manage
slipped muscle in squint surgery? Follow its sheath, avoid turning the
globe to other side, beware of oculocardiac reflex. Other complications
of squint surgery and their management? Perforation, malignant hyperthermia
from anaesthesia.

A scenario of an infant 3 months old with
bilateral dense cataracts. How do you manage? Assess the general condition,
systemic associations, exclude secondary causes, do the 2 eyes within 2
weeks. Steps of surgery in details? General anaethesia, anterior
chamber maintainer, scleral tunnel, anterior capsulotomy using a
vitrous cutter, irrigation and aspiration, post capsulotmy, anterior vitrectomy.
How do you do IOL calculation in infants? Less by 20% before 2 years and
10% between 2-8 years. Why? To accommodate for myopic shift as the globe
grows. When to implant? After 1.5 years.

An FFA showing a full thickness macular hole.
Grades of macular hole? Incidence in the other eye? Management? What is
the most important single step during surgery? ILM peeling. How can you
identify the ILM? Stained by trypan blue, ICG or fluorescence.

The examiner draw a right fundus with an upper
temporal RD? Where would you expect the tear? At1 o’clock using Linscoff's
rule. Management? This is an emergency as the macula is not involved. Gas,
scleral buckle, or primary vitrectomy and saved by the bell.

Medical Ophthalmology(An Indian and an English examiner)

The Indian examiner

A picture of ring corneal infiltration with
feathery appearance and satellite lesions manage? I mentioned infective
keratitis and would like to take a history to learn about trauma involving
organic matters and contact lens wear. What is your differential diagnosis:
fungal, bacterial or acanthmeoba? How to confirm it? Asked about
Gram and Giemsa stains, blood agar,chocolate agar, thioglycolate broth,and
Sabouraud media and non-nutrient agar enriched with E.choli. How
long does it take for fungal to grow? 2weeks. How to confirm early?
By stain with Giemsa stain,KOH ,and direct view of hyphae by confocal microscopy
or even PCR.

Fundus picture: severe neovascularization
at the optic disc (NVD) and elsewhere (NVE). I will regard this as
an medical emergency and will arrange for immediate PRP what are the complications
of PRP? I mentioned short and long term complications.

A picture of bilateral mild upper eyelid retraction.
I suspected TED. What other manifestations of TED? Soft tissue infiltration
,corneal exposure, optic neuropathy, restrictive myopathy, what is the
cause of lid lag fibrosis of levator.

Another picture of right hypotropia with upper
lid lag. I gave a differential diagnosis of TED, orbital floor
fracture, limited elevation double elevator palsy, IR fibrosis or entrapment,
brown syndrome. How to differentiate double elevator palsy and TED
lid lag? Forced duction test how to treat IR fibrosis in TED.
After the condition become stable for at least 6 months and there is diplopia
in primary position or reading position. If there is significant
proptosis, orbital decompression to be done first if needed before
inferior rectus recession usingadjustable suture.

A picture of anterior segment with PXS.
What are the ocular manifestations? Angle pigmentation, high IOP,
weak zonule, poor pupil dilatation. What would you like to examine? The
angle, IOP, fundus, visual field. Then he gave me fundal picture of the
patient optic disc with C/D 0.8 so it is most probably glaucomatous.

2nd Examiner

A picture of closed punctum what are
the possible causes? Congenital obstruction, inflammation, infection.

A picture of small inferotemporal pigmented
conjunctival lesion told that the complaint is dimined vision. I
noticed a sectorial hyperpigment of the iris so I suspected intraocular
tumor with sclera invasion. Good! How can you confirm it? Fundal examination,
U/S, UBM then he gave the U/S picture with some colours in it. I
told him that I am not familiar with coloured ultrasound but I think it
shows Doppler U/S with a highly vascular homogenous mass. Good!

A picture of an old man with left proptosis
and dystopia complaining of double vision. I gave a DD of proptosis
using the mnemonic VEIN (Vascular, Endocrine, Inflammatory
and Neoplastic) how to manage VA, pupil, measure degree of
proptosis, corneal sensation, ocular motility, optic nerve functions, fundal
examination.

A picture of giant papillary conjunctivitis
(cobbled stone). I mentioned it may be VKC or contact lens related. How
to manage VKC. Take history for severity, recurrence of attacks
examine the eye for corneal ulcer or complication of previous treatment,
then I will begin treatment with topical mast cell stabilizer such as sodium
cromoglycate and anti histaminic then topical steroids how to treat shield
ulcer debride mucous, therapeutic contact lens and steroids.

Case 1: The Indian examiner asked me to examine
the adnexae of a young lady. There was mild right ptosis and some mild
lid twitches when she talks and mild lid retraction of the left side.
Asked why the other eye has lid retraction? Hering's Law. I
measured the ptosis and tested the eyes for Bell's phenomenon. While lifting
the ptotic lid the retraction of the contralateral lid disappeared. Ocular
motility was normal. Testing jaw movement brought out the winking thus
confirming Marcus- Gunn jaw winking ptosis. Asked about treatment?
Bilateral levator recession followed by brow suspension to abolish the
winking and achieve symmetry.

Case 2: The English examiner asked me to examine
the right anterior segment of an old lady. There was ECCE with in
the bag IOL and mild PCO noticed only with retro-illumination. The
wound was closed with continuous 10/0 nylon sutures. When I mentioned these
findings he asked me to examine her posterior segment with a 90D lens?
There was a macular hole and drusen. He asked me to examine the left
posterior segment? There was a retinal detachment with a grade C circumferential
PVR.

Case 3: The Indian examiner asked me to examine
the anterior segment af an old lady. There was diffuse corneal edema, up-drawing
pupil due vitreous in the anterior chamber and a decentered PCIOL. Asked
about the causes of oedema? Fuchs' dystrophy, complicated surgery or vitreous
wick syndrome.

Case 4: The English examiner asked me to examine
a middle age man using an indirect ophthalmoscope? There were bilateral
chorioretinal coloboma involving the posterior poles and extending inferonasally.
There were also bilateral inferonasal iris coloboma. Questions
on possible systemic and ocular associations?.

Case 5: The Indian examiner asked me to perform
cover/uncover test on a young man? The left vision was poor for distance
with and without glasses, so I did the test only for near . There was a
left exotropia. Then asked to examine the primary and secondary angle of
deviation? There were apparently equal. Then moved on to examine the ocular
motility and found to be normal.

Case 6: The English examiner asked me to examine
an old lady using a 90D lens. There was a right clinically significant
macular oedema due to diabetes mellitus. Then I was asked tto examine
her using the binocular indirect 20D! There waere bilateral myopic changes
with right moderate NPDR +CSME and left ,ild NPDR with scattered laser
marks. Questions on the management of CSME?

Case 7: The Indian examiner asked me to examine
a 5 years old girl using a torch? There was bilateral severe corneal opacities
and vascularisation and the left had anterior staphyloma. Questions
on possible causes? I mentioned congenital (corneal dystropy, congenital
glaucoma) or acquired (infections, vitamin A deficiency, trauma, inflammatory).
The examiner was not satisfied but the bell saved me !!!!!!!!!!!!!!!!!.

The results were announced 3 hours after
the clinical examination which were the most stressful 3 hours of my life
but the ending was a HAPPY one!

I am happy to help any colleague of mine
with this examination and my e-mail is: mraslan75@gmail.com